Attention-deficit/hyperactivity disorder in adults: an overview

A psychopathological study into the relationship between attention deficit hyperactivity disorder in adult patients and recurrent brief depression

OBJECTIVE

Clinical and epidemiological observations and neurobiological data suggest that there might be an inherent link between attention deficit hyperactivity disorder (ADHD) and recurrent brief depression (RBD). In this psychopathological study, we investigated the comorbidity between these two conditions.

METHOD

Using an index patient approach 40 adult out-patients fulfilling the criteria for ADHD were investigated for lifetime history of RBD and another 40 out-patients with the primary diagnosis of RBD were investigated for a lifetime history of ADHD.

RESULTS

We found a high prevalence of RBD in patients with ADHD (70%) while the prevalence of ADHD in the index sample with RBD was smaller (about 40%).

CONCLUSION

In terms of comorbidity ADHD was the second commonest psychiatric disorder in patients with RBD next to other affective disorders. The psychopathological pattern of lifetime comorbidity might be of clinical relevance in terms of medical treatment.

A qualitative study of Australian GPs' attitudes and practices in the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD)

BACKGROUND

The importance of general practice involvement in the care of attention-deficit/ hyperactivity disorder (ADHD) is increasing due to the rising numbers of patients who present with the disorder. It has been suggested by consensus bodies that GPs should be identifying and referring patients at the severe end of the ADHD spectrum and managing those with less severe symptoms. However, GPs' views of their role in ADHD care are unknown.

OBJECTIVE

Our aim was to explore the attitudes and practices of Australian GPs towards the diagnosis and management of ADHD.

METHODS

We conducted a series of focus groups to explore GPs' beliefs regarding the causes of ADHD, their perceived role in ADHD diagnosis and management and their views on the role of behaviour therapies and pharmacotherapies in ADHD management. The subjects were 28 GPs in six focus groups.

RESULTS

GPs in this study did not want to be the primary providers of care for patients with ADHD. Participants indicated a preference to refer the patient to medical specialists for diagnosis and treatment of ADHD, and expressed low levels of interest in becoming highly involved in ADHD care. Concerns about overdiagnosis and misdiagnosis of the disorder, diagnostic complexity, time constraints, insufficient education and training about the disorder, and concerns regarding misuse and diversion of stimulant medications were the reasons cited for their lack of willingness.

CONCLUSIONS

The Australian GPs in this study identify a role for themselves in ADHD care which is largely supportive in nature, and involves close liaison with specialist services.

Biased paternal transmission of SNAP-25 risk alleles in attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is the most common childhood psychiatric disorder, affecting 5-10% of school-age children. Although the biological basis of this disorder is unknown, twin and family studies provide strong evidence that ADHD has a genetic basis involving multiple genes. A previous study found an association between ADHD and two polymorphisms in the 3' untranslated region (UTR) of SNAP-25, a gene encoding a synaptic vesicle docking protein known to play a role in the hyperactivity observed in the Coloboma mouse strain. In this paper, we test biased transmission of the 3' UTR SNAP-25 haplotype using a larger ADHD sample of 113 families with 207 affected children. Using the transmission disequilibrium test (TDT), we found a trend consistent with biased transmission of the TC haplotype of SNAP-25 in all transmissions and detected a significant distortion (P=0.027) when paternal transmissions were evaluated.

Beck Depression Inventory-II items associated with self-reported symptoms of ADHD in adult psychiatric outpatients

The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) and the Conners' Adult ADHD Rating Scale-Self-Report: Screening Version (CAARS-S:SV; Conners, Erhardt, & Sparrow, 1999) were administered to 371 (64%) female and 204 (36%) male adult (> 18 years old) outpatients who were diagnosed with various psychiatric disorders to determine whether any of the 21 items or subsets of items in the BDI-II were related to symptoms of attention deficits and hyperactivity as measured by the CAARS-S:SV DSM-IV Total ADHD Symptoms scale (attention-deficit/hyperactivity disorder [ADHD] Symptoms). Stepwise multiple-regression analyses found that the BDI-II Concentration Difficulty explained 30% of the variance in these total scores. Ratings > 1 for the BDI-II Concentration Difficulty item were discussed as being useful for ruling out possible symptoms of ADHD.

Does parental ADHD bias maternal reports of ADHD symptoms in children?

Within families, co-occurring attention-deficit/hyperactivity disorder (ADHD) in parents and children may be common. The authors evaluated the hypothesis that parental ADHD may lead to a reporting bias of ADHD symptoms in offspring. They combined 2 family case-controlled studies of ADHD using structured interviews. They compared rates of maternal reported ADHD symptoms among 3 groups of ADHD children: no parental ADHD (n = 231), mother with ADHD (n = 63), and father with ADHD (n = 57). With the exception of 1 symptom, the rates of reporting between groups did not differ. There was no evidence that the discrepancy between maternal reports and self-reports of symptoms differed by parental ADHD. Results were similar across child gender or referral status. These results do not support the notion that parental ADHD affects maternal reports of offspring ADHD.

The association of preceding traumatic brain injury with mental disorders, alcoholism and criminality: the Northern Finland 1966 Birth Cohort Study

The purpose of this study was to test the hypothesis that traumatic brain injury (TBI) during childhood and adolescence is associated with psychiatric disorders, heavy alcohol use and criminal offenses in adulthood. We made use of an unselected, general population birth cohort (n=12058) in Northern Finland, which was followed up prospectively up to the age of 31. The data on TBIs of the cohort members were collected from the hospital case notes of the outpatient clinics of the hospitals in the region and from the Finnish Hospital Discharge Registers (FHDR). The data on mental disorders including alcohol diagnoses were also collected from the FHDR after a careful validation process. The Ministry of Justice provided information on criminal offenses for all subjects. The final number of subjects in our study was 5589 males and 5345 females. We found that after controlling for confounders, TBI during childhood or adolescence increased the risk of developing mental disorders two-fold (OR 2.1, 95% CI 1.1-3.6) and TBI was significantly related to later mental disorder with coexisting criminality in male cohort members (OR 4.1, 95% CI 1.2-13.6). The results support the TBI's association with psychiatric morbidity, which should not be overlooked when treating psychiatric patients, especially those with comorbid criminality.

Efficacy of atomoxetine versus placebo in school-age girls with attention-deficit/hyperactivity disorder

OBJECTIVE

The efficacy of atomoxetine was assessed in school-age girls with attention-deficit/hyperactivity disorder (ADHD). Atomoxetine is a potent inhibitor of the presynaptic norepinephrine transporter with minimal affinity for other noradrenergic receptors or for other neurotransmitter transporters or receptors.

METHODS

A total of 291 children who were 7 to 13 years of age and met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for ADHD participated in 1 of 2 combined, double-blind, placebo-controlled, multisite, identical clinical trials. This intent-to-treat subset analysis examined the effects of atomoxetine versus placebo in 51 girls who were randomized to atomoxetine (n = 30) or placebo (n = 21) for 9 weeks. ADHD symptoms were assessed using parent- and investigator-rated scales.

RESULTS

Atomoxetine was superior to placebo on the following measures: the Attention-Deficit Hyperactivity Disorder Rating Scale-IV-Parent Version: Investigator Administered and Scored Total Score; the Inattentive and Hyperactive/Impulsive subscales of the Attention-Deficit Hyperactivity Disorder Rating Scale-IV-Parent Version: Investigator Administered and Scored Total Score; the ADHD Index subscale of the Conners' Parent Rating Scale-Revised: Short Form; and the Clinical Global Impressions of Severity of ADHD. Statistically significant efficacy was seen 1 week after randomization and remained so for the duration of the study. One patient from each of the atomoxetine and placebo groups discontinued the study as a result of an adverse event.

CONCLUSION

Atomoxetine was found to be effective and well tolerated for the treatment of ADHD in school-age girls.

Prevalence of attention deficit/hyperactivity disorder among adults in obesity treatment

BACKGROUND

Bariatric patients showing poor "focus" during treatment more often failed to lose weight or maintain reduced weight. Evaluation of these patients identified a number having attention deficit/hyperactivity disorder (ADHD), evidently a potent factor limiting successful weight control. After searches found no published reports describing comorbid ADHD and obesity, this report was conceived to begin exploring the prevalence and characteristics of these patients.

METHOD

Clinical records of 215 patients receiving obesity treatment during 2000 were reviewed. Data collected and analyzed included age, sex, beginning and ending body mass index (BMI), number of clinic visits, months of treatment, and diagnostic category (ADHD, some ADHD symptoms, non-ADHD). DSM-IV criteria were used, except age of onset was modified to <= 12 years.

RESULTS

Whole sample ADHD prevalence was 27.4% (CI:21.1,32.9), but 42.6% (CI: 36.3% to 48.9%) for BMI >= 40. Mean weight loss among obese patients with ADHD (OB+ADHD) was 2.6 BMI (kg/m2) vs. 4.0 for non-ADHD (NAD) (p < 0.002). For BMI >= 40, OB+ADHD had BMI loss 2.9 vs. 7.0 (NAD) (p < 0.004). OB+ADHD had more clinic visits, with a trend toward longer treatment duration.

CONCLUSIONS

ADHD was highly prevalent among obese patients and highest in those with extreme obesity. Comorbid obesity and ADHD symptoms rendered treatment less successful compared to NAD counterparts. Reasons for the comorbidity are unknown, but may involve brain dopamine or insulin receptor activity. If replicated in further studies, these findings have important implications for treatment of severe and extreme obesity.

Frontoorbital volume reductions in adult patients with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a common psychiatric disorder in childhood and adolescence and in a considerable number of patients it persists into adulthood. A network of brain regions have been shown to be abnormal in ADHD. In the present study we used magnetic resonance volumetry to investigate a possible role of the orbitofrontal cortex (OFC). Eight never medicated male patients fulfilling diagnostic criteria for ADHD and 17 male healthy controls were investigated. There was a significant reduction of the volume of the left OFC in patients with ADHD. It remains unknown whether small volumes are a primary deficit or a result of dysfunctional activation during childhood in terms of a residual deficit or a specific type of adult outcome of the disease.

Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence

In this 12-week double-blind placebo-controlled trial of methylphenidate (MTP) versus placebo in 48 cocaine-dependent attention-deficit/hyperactivity disorder (ADHD) adults, the authors sought to determine whether MTP would be safe, control ADHD symptoms, and affect cocaine use. Efficacy indexes revealed significantly greater ADHD symptom relief in the MTP group. There were no group differences in self-reported cocaine use, urinalysis results, or cocaine craving. Because of the relatively small sample size, the results are preliminary. However, we found that MTP improved subjective reports of ADHD symptoms and did not worsen cocaine use while participants were in treatment.

Big five dimensions and ADHD symptoms: links between personality traits and clinical symptoms

Attention-deficit/hyperactivity disorder (ADHD) in adulthood is conceptualized as originating in childhood. Despite considerable theoretical interest, little is known about how ADHD symptoms relate to normal personality traits in adults. In 6 studies, the Big Five personality dimensions were related to ADHD symptoms that adults both recalled from childhood and reported concurrently (total N = 1,620). Substantial effects emerged that were replicated across samples. First, the ADHD symptom cluster of inattention-disorganization was substantially related to low Conscientiousness and, to a lesser extent, Neuroticism. Second, ADHD symptom clusters of hyperactivity-impulsivity and oppositional childhood and adult behaviors were associated with low Agreeableness. Results were replicated with self-reports and observer reports of personality in community and clinical samples. Findings support theoretical connections between personality traits and ADHD symptoms.

Does maternal ADHD reduce the effectiveness of parent training for preschool children's ADHD?

OBJECTIVE

To assess the impact of maternal attention-deficit/hyperactivity disorder (ADHD) symptoms on the effectiveness of a parent training (PT) program for preschool ADHD.

METHOD

Eighty-three 3-year-old children with ADHD and their mothers selected from two community cohorts living in Hampshire, England (1992-93 and 1995-96, respectively), completed an 8-week PT program. ADHD symptoms and a number of other parent and child factors, including adult ADHD symptoms, were measured prior to the start of treatment (week 1: T1), immediately after treatment (week 8: T2), and at 15 weeks follow-up (week 23: T3).

RESULTS

Mothers were divided into three groups on the basis of their scores (T1) on the Adult AD/HD Rating Scale (high, medium, low). Children of mothers in the high-ADHD group displayed no improvement after PT, whereas the levels of ADHD symptoms of the children of mothers in either the medium or low ADHD groups reduced substantially (F(4,60) = 3.13, p < .05). This association persisted after other child and maternal factors were controlled for in multiple regression analyses (beta > .30, p < .05).

CONCLUSIONS

High levels of maternal ADHD symptoms limit the improvement shown by children with ADHD after a program of PT. This effect was unrelated to other aspects of maternal mental health and child functioning. The treatment of parental ADHD may be a prerequisite for the success of psychosocial interventions for childhood ADHD.

A review of adult ADHD: a neuropsychological and neuroimaging perspective

Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder which effects an estimated 3% to 5% of children. Despite estimates that ADHD persists in 30% to 70% of adults having had the disorder in childhood, ADHD in adulthood remains controversial. This report summarizes current thinking in the diagnosis and etiology of adult ADHD. Most theories posit that ADHD is related to anomalies in frontal lobe function and dopaminergic transmission. However, there is debate as to whether ADHD is a unitary disorder with different manifestations, a syndrome, or multiple disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, classifies ADHD into inattention, hyperactivity-impulsivity, and combined subtypes. Although problems with cognition are core ADHD symptoms, self-reporting has not been a reliable predictor of neuropsychological test performance. Nevertheless, we suggest that a performance-based diagnosis, including empirically derived, age-sensitive neuropsychological tests, provides the best hope of dissociating ADHD from psychiatric disorders with similar symptoms. We also describe the promise of new neuroimaging technologies, such as functional magnetic resonance imaging, in elucidating the pathophysiology of ADHD and similar psychiatric disorders.

Familial links between attention deficit hyperactivity disorder, conduct disorder, and bipolar disorder

Although family, twin, and adoption studies indicate that attention deficit hyperactivity disorder (ADHD) is a familial condition with a robust genetic component, molecular genetic studies of candidate genes have produced inconsistent findings. One of the challenges to elucidating the genetic architecture of ADHD is its potential genetic heterogeneity. Therefore, efforts are needed to identify etiologically homogeneous subgroups of subjects with ADHD for use in genetic studies. The current article reviews evidence suggesting that parsing ADHD subjects based on comorbidity with conduct and bipolar disorders may yield familial subtypes that are suitable for genetic analyses.

Attention deficit hyperactivity disorder (ADHD) and substance use disorders

Attention deficit hyperactivity disorder (ADHD) is a common childhood disorder that often continues to manifest symptoms into adulthood. In children and adults, this condition may contribute to addictive vulnerability. Several factors are common to the developmental psychopathology of these conditions, suggesting an underlying deficit in behavioral regulation as an explanation for this comorbidity. Developmentally, faulty learning processes or attempts to self-medicate dysfunctional behavior may contribute to the pathogenesis of substance use disorders. Substance abuse itself also may contribute to the development of attentional deficits and behavioral dysregulation through direct (eg, prenatal or self-inflicted exposures to neurotoxic substances) and indirect (eg, poverty, neglect, abuse) mechanisms. Because ADHD can be identified prior to the peak onset of substance use, effective treatment of this common disorder may reduce the development of substance use disorders. Adult ADHD may also contribute to the development and maintenance of substance use disorders Substance abuse patients may particularly benefit from treatment of this comorbidity.

Striatal neuronal loss or dysfunction and choline rise in children with attention-deficit hyperactivity disorder: a 1H-magnetic resonance spectroscopy study

Twelve previously untreated boys suffering from attention-deficit hyperactivity disorder (ADHD) were investigated by using proton magnetic resonance spectroscopy (1H MRS) before and after one dose (10 mg) of methylphenidate. Pre- and post-methylphenidate spectra were acquired bilaterally in the globus pallidus. Peaks of N-acetylaspartate (NAA), choline (Cho), myo-inositol, glutamate and creatine (Cr) were measured and the ratios of the peaks were calculated and compared with data from ten matched controls. In children having ADHD, NAA/Cr ratio decreased significantly in the bilateral striatum while Cho/Cr ratio showed a mild unilateral increase. One oral dose of methylphenidate did not affect the ratios significantly. These findings suggest that the striatum was bilaterally involved in pediatric ADHD patients. Approximately 20-25% of neurons may have died or may be severely dysfunctional. There seems to be a mild hyperactivity of the cholinergic system.

Use of venlafaxine in other psychiatric disorders

Venlafaxine is a medication available by prescription in the U.S. both in an immediate release and an extended release formulation. Preclinical studies indicate it has the effect of potently blocking the serotonin and norepinephrine transporters. Venlafaxine is approved by the FDA for the treatment of major depressive disorder and generalized anxiety disorder. Suggestive evidence, mostly from open label case series, indicates efficacy of venlafaxine in several other conditions including panic disorder, social anxiety disorder, obsessive compulsive disorder, trichotillomania, ADHD, chronic pain, and fibromyalgia. The limited evidence supporting efficacy in these conditions is reviewed. Additional randomized clinical trials with placebo controls are indicated.

Attention-deficit disorder in adults with or without hyperactivity: where is the difference? A study in humans using short echo (1)H-magnetic resonance spectroscopy

The DSM-IV distinguishes three subtypes of attention deficit hyperactivity disorder: The predominantly inattentive subtype (ADD), the hyperactive-impulsive subtype (ADHD) and the combined subtype. We used short echo time (1)H-magnetic resonance spectroscopy (TE=30 ms, TR=3000 ms) for absolute quantification of neurometabolites using the LC model algorithm to investigate a possible metabolic neuropathology in adult patients with ADD and ADHD and compared their spectra with healthy controls (n=5 in each group). Spectra were acquired in the left dorsolateral prefrontal cortex and the left striatum. There was a significant group difference in N-acetylaspartate (NAA) concentration in the left dorsolateral prefrontal cortex distinguishing patients with the ADHD from patients with pure ADD and healthy controls. The absolute NAA concentration was significantly reduced only in the ADHD group. Since NAA-depletion reflects a state of neuronal dysfunction, this finding indicates evidence of subtle left prefrontal neuropathology in ADHD in adults.